Inquest into the Death of Child C (Name Subject to Suppression Order)
Deceased
Child C
Demographics
15y, female
Date of death
2020-11-27
Finding date
2023-01-24
Cause of death
Head injury
AI-generated summary
Child C, a 15-year-old girl in Department of Communities care, died from a catastrophic head injury sustained when she fell from a moving car on 27 November 2020. She had self-selected to return to her mother's care in July 2019 at age 14½ following foster care placement breakdown. The coroner found the Department's decision-making regarding her care was appropriate and that her mother provided a safe home environment. However, the Department failed to complete all required Care Planning processes, including Quarterly Care Reports and annual Health Care Planning assessments. Record-keeping deficiencies meant decision-making rationales were not properly documented. The coroner identified oversights in care planning documentation and formalisation of the unendorsed placement, though these did not impact the actual quality of care provided. No clinical or preventable factors related to medical care were identified.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Clinical conditions
Contributing factors
- Fall from moving car
- Driver with provisional licence and blood alcohol level 0.062%
- Passengers riding on exterior of vehicle
- Unsafe driving practices
- High-risk behaviour by young people
Coroner's recommendations
- Department to strengthen guidance for child protection workers by using mandatory 'must' language instead of 'should'
- Implementation of Unendorsed Placement Project to review management of children in self-selected living arrangements
- Application of At-Risk Youth Strategy 2022-2027 to improve life outcomes for vulnerable young people aged 10-24 years
- Completion of all required Care Planning processes for children residing with parents, including Quarterly Care Reports and annual Health Care Planning assessments
- Formal endorsement and documentation of decision-making rationale for placements with parents
Full text
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